IRCCS - Policlinico “S. Matteo”

Cattedra di Anestesia e Rianimazione

Università degli Studi di Pavia

DONAZIONE A CUORE NON

BATTENTE NELLA REALTA’

ITALIANA

Dr. Marinella Zanierato

SSD Coordinamento Donazione e Trapianti

Rianimazione I

Prolonged WIT…very variable period of ischemic damage due to cardiac standstill

(no-flow) followed by cardiac resuscitation (low-flow) with a varied

degree of effectiveness……no-flow > 30 min is associated to very

poor graft survival…….

D Monbaliu, J Pirenne, D Talbot, J Hepatology 2012; 56: 474-485

Italian DCD program started in 2007

The possible

scenarios

Good quality of CPR

(autopulse)- FV/TV

Time ≤ 60 min

End-tidalCO2> 10 mmHg

In h

osp

ital

Assesment of time from

collapse to door

Now-flow < 80 min

ECLS

Program

Assesment of end-tidal CO2

Indication for ECMO support

No-flow < 6 min

Ou

t of h

osp

ital

Median time to CRP 7 min (6-

8)

Median time to ECMO 93 min

(74-107)

After a median of 20 hours

(16-22) of ECMO all pts of this

subgroup died:

in 3 pts BD

in 4 pts ECMO was

withdrawn because ineffective

Ineffective

ECLS

Significative correlation between CPR duration

pre-ECLS and mortality (no flow/low flow)

0

20

40

60

80

100

120

Dead Alive

100,5

49

Min

ute

sCPR duration

P < 0.002

ECLS

ineffective

DBD donors

Neurological

criteria

DCD donors

Cardiocirculatory

criteria

2015

Pavia DCD program started in 2007

Actions for organ protection before

death

Alba program

WITNESSED CARDIAC ARREST (CA)

BLS/ACLS

DIAGNOSIS OF IRREVERSIBLE CA

ARRIVAL IN

HOSPITAL

STOP ACLS AND

RECORD EKG

OVER 20’

Check for

exclusion criteria:

Age > 18< 65 yrs

Past medical

history

Heparin bolus

infusion

CONSENT BY NEXT OF KIN

<15’

Normothermic

Regional Perfusion

(NRP)

Mutidisciplinary team evaluation: No-

flow >15 min, low- flow >60-80min,

Asystolia , ET CO2 < 10 mmHg, no

indication to ECMO support

WITNESSED CARDIAC ARREST (CA)

BLS/ACLS

ARRIVAL IN

HOSPITAL

STOP ACLS AND

RECORD EKG

OVER 20’

Death certified

(DM 2008, n. 582)

CONSENT BY NEXT OF KIN

to donation or to NRP

< 15’

< 70’

NRP

120-110’

Alba Program

The process of uncontrolled

DCD

Spain

France

Italy

Switzerland

US, NY City

DONOR ENROLMENT CRITERIA

• Age 15 – 65 yrs

• Resuscitation start within 15 min

• Cardiac arrest witnessed by familiar or colleagues

• Refractory to acls

• Absence of hemodynamic instability for > 60 min or severe

hypotension (< 60 mmhg) prior to cardiac arrest

• Known cause of death, ruling out violence

• Time to hospital arrival < 90 min

DCD PROTOCOL

120 min

Warm ischemia time

(WIT)

1 – 4 hours (max 6 h)

ACLS

Death certified

CPR

EK

G Cold storage/

Perfusion

machine

20

min

15

min

‘Real’ WIT (no flow)

Cardiac ArrestNormothermic

Regional PerfusionHarvest

Trasplant

Time point uncontrolled DCD

Maastricht Classification

Definition Where

I Dead on arrival

Spain, France, Italy

II Unsuccessful resuscitation

IIICardiac arrest awaited after withdrawal of life

support in patients who are not brain deadBelgium, United

Kingdom, Netherlands,

Australia, USA, New

ZealandIV Cardiac arrest after brain death

I, II, uncontrolled

III, IV: controlled

End-of-life care and

intensivist

Treatment Futility

The Pathway to Organ

DonationSevere and

irreversible

Brain Injury

Irrecoverable

loss of brain

function

Withdraw of

Care

Death by

Neurologic

Criteria

Donation after

Cardiac Death

(DCD)

Donation after

Brain Death

Ischaemic injury

asystolecold

perfusion

transplant

reperfusionwithdrawal

cold

ischaemia

decision re

WLST

functional

warm

ischaemia

agonal

period

SBP < 50mmHg

SaO2 < 75%

PHASE I

PHASE II

Reperfusion

NRPACC

TIME

GLOBAL

ISCHEMIARIPERFUSION

INJURY

NORMOTERMIC RECIRCULATION

• Heparin bolus (300

UI/kg) before no touch

period

• Femoral artery and

vein cannulation

• Fogarthy catheter

inflated at the

supraceliac aorta

• Pump flow during NRP

: 1.7-3 l/min

• NRP time: 240-480 min

NRP could shift the warm

ischemia time to an ischemic

preconditioning

Normothermic Regional

Perfusion (NRP)

Aortic Balloon

WHICH ARE THE BEST PREDICTORS OF

SUBSEQUENT ORGAN FUNCTION,

DURING NRP?

All studies examine short-term markers

lactate

glucose metabolism

transaminases

ph

oxygenation

…..

WARM

ISCHEMIA

TIME

…very variable period of ischemic

damage due to cardiac standstill (no-

flow) followed by cardiac resuscitation

(low-flow) with a varied degree of

effectiveness……no-flow > 30 min is

associated to very poor graft

survival…….

Definition of warm ischemia time

Relationship of hepatic circulation, renal circulation with

oxygen saturation and mean arterial pressure in DCD III

Results: severe cellular

changes before

reperfusion. Early

histologic evidence

suggests severe

hepatocyte and biliary

cell disruption

Visual inspection

Perfusion Machine

Biopsy

Results (sept 2008-march 2016): 65 potential

DCD

63 unreversible CA/

2 severe brain injury

62 Male/3 female

Mean age 50yrs (36-63)

Mean no- flow 10,4 min

Mean low flow 72,8 min

Low-flow > 120 min 17

pts

29 effective

DCD donors

29

8

0

5

10

15

20

25

30

35

Consent Opposition

Consent

ecls ; 13; 36%

no consent; 8; 22%

anamnesi sosp onco, 2, 6%

tempi ischemia lunghi, 13, 36%

Non idonei = 36 organi

0

5

10

15

20

25

30

35

<20 20-30 30-40 40-50 50-60 60-70 >70

DBD AGE

N° Donatori

0

2

4

6

8

10

12

31 - 40 41 - 50 51 - 60 61 - 70

Distribuzione per etàDCD AGE

PAVIA

Donors’ Age

HBD / DCD

2009/2016

mean WIT 183,33 min

Mean WIT 163 min in

effective donors

Lactate trend during NRP

10

12

14

16

18

20

lac_

1 2 3 4 5 6time

lac_ lb/ub

10

15

20

25

lac_

1 2 3 4 5 6time

0 1

lb/ub

510

15

20

25

lac_

1 2 3 4 5 6time

0 1

lb/ub

Lactate trend in

kidneys

transplant

Lactate trend in livers

transplant

Transplanted

Not transplanted

Transplanted

Not transplanted

10

15

20

25

30

trap_ren

time=1

lac_

0 1

Data in press

Kidneys (58 grafts,29 pts)

histology; 8; 18%

Cold storage, 1, 2%Suspected oncologic

lesion, 2, 4%

Macroscopic evalutation, 6,

13%

retrieved;42; 63% Not retrieed; 16; 36%

58 Retrieved organs

42 kidneys

retrieved

underwent Machine

Perfusion( 4-18 hs)

Kidneys with

resistance > 0.4

were excluded

• 30 grafts were

transplanted:

• 21 in Pavia

• 5 in other center

• 4 no recipients

Mean resistence: 0.22

Mean flow: 0.95 ml/min

PERFUSION PARAMETERS

Kidney function assessment at 30 days

During the first month serum

creatinine is high, but this

improves with time as renal

tubolar epithelium is regenerated

Histology showed severe

tubular necrosis

OUTCOME

Mean follow up was 4 years (min 1 yr,max 8 yrs)

PNF: 4% (1 pts)

DGF :75%

Acute rejection: 0%

1-year graft survival

98%

1-year patient survival

98%

Actuarial patient

survival:93,4%

Mean GFR during follow up was 43 ml/min without any

statistical difference with BDD

% p

ati

en

t s

urv

iva

l

40

50

60

70

80

90

100

years post-transplant0 1 2 3 4 5

DCDDBD

Standard versus expanded versus

DCD

ALT TRENDS

DURING NRP

9 cases: 7 DCD II

2 DCD III

Liver

Postoperative course

ALT

-500

0

500

1000

1500

2000

2500

3000

3500

ALT pre ALT arrivo ICUALT POD 1 ALT POD 3 ALT POD 5 ALT POD 7

…..And the

lungs?

Dual

preservation

Conclusion 1

Fieux F et al, Crit Care 2009; 13: R141

There is the need to improve the quality of these graft by ex-

situ preservation technique which increases the chance of

immediate function after transplantation

Conclusion 2

The key element of in-situ NRP is to mantain the organs in a

normal physiological state providing oxygen and nutrients to

support aerobic metabolism